CDC Says Antibiotic Overuse Puts Patients at Risk

by Michael Smith Michael Smith North American Correspondent, MedPage Today
March 04, 2014

Doctors in some hospitals are prescribing three times more antibiotics than physicians treating similar patients in other institutions, according to the CDC.

The variation suggests that in several common situations, antibiotic prescribing could be improved by more than 30%, the agency said in a Vital Signs study online in Morbidity and Mortality Weekly Report.

"We estimate that even a modest reduction in unnecessary or inappropriate prescribing would have major benefits in terms of reducing the number of infections, super-infections, and cases of C. difficile," Frieden said.

The Society for Healthcare Epidemiology of America wasted no time in signing on to Frieden’s message noting that routine overuse of antibiotics puts patients in harm's way.

In a statement sent to journalists, Sara Cosgrove, MD, MS, associate professor of medicine and epidemiology at Johns Hopkins University and chair of SHEA’s Antimicrobial Stewardship Taskforce said, "Antimicrobial stewardship programs can help clinicians make good choices about the antibiotics they prescribe for their hospitalized patients."

The agency used several data sources to describe why and how often antibiotics are used in U.S. acute care hospitals, illustrate the potential for better use in some common clinical situations, and estimate potential reductions in Clostridium difficile infection that could be achieved with improved antibiotic use.

One outcome of the analysis, Frieden said, was a seven-point program of antibiotic stewardship that all hospitals should implement:

Support for the program from top administrators, with human, financial, and information technology resources

Accountability through a single physician lead

Drug expertise through a single pharmacy lead

Action to improve prescribing, including requiring prescriptions to be re-assessed within 48 hours to check drug choice, dose, and duration

Education for clinicians

Tracking local prescribing and resistance information

Reporting such data directly to clinicians

"Every single hospital in this country should have an antibiotic stewardship program," he said, adding that such programs "save lives and they also save money."

The CDC analysis of data from the MarketScan Hospital Drug Database showed that in 2010, 55.7% of patients discharged from a sample of 323 hospitals received antibiotics during their inpatient stay.

Also, the agency's Emerging Infections Program -- a network of state health departments, academic institutions, and local collaborators -- found that in 2011, 49.9% of all treatment antibiotics were prescribed in one or more of three scenarios: lower respiratory infections, urinary tract infections (UTI), or presumed resistant Gram-positive infections.

Reviews of treatment in cases of UTI in patients without catheters and in patients treated with intravenous vancomycin showed that antibiotic use could have been improved in 37.2% of the cases, the CDC report said.

In UTI, for instance, doctors should be certain that a patient has an infection rather than simple colonization, Frieden said. "Often you'll have urine cultures with all sorts of bacteria in them [and] that doesn't necessarily mean infection," he said.

Indeed, the CDC report comes just a few days after Canadian researchers reported a simple intervention that they found markedly reduced the use of antibiotics in patients with asymptomatic bacteriuria.

The change was simply not to routinely report the result of urine cultures to doctors, according to Jerome Leis, MD, of Sunnybrook Health Sciences Centre in Toronto, and colleagues.

In cases without symptoms, the intervention reduced the rate of antibiotic prescribing by 36%, they reported.

In the CDC report, data for 2012 from the National Healthcare Safety Network found that critical care units reported higher rates of antibiotic use compared with ward locations -- medians of 937 and 549 days of therapy, respectively, for every 1,000 days on the ward.

Variability in prescribing among various patient locations was highest -- a threefold difference between 90th and 10th percentile -- in combined medical/surgical wards, the researchers found.

In a retrospective cohort study in two large academic centers, the risk for C. difficile infection among patients unexposed and exposed to antibiotics was 6.8 and 24.9 per 1,000 discharges, respectively, the report said.

Those numbers yielded an adjusted relative risk for development of C. difficile infection within 180 days after inpatient exposure to broad-spectrum antibiotics of 3.1 (95% CI 2.5 to 3.8).

Mathematical modeling suggested that the effect of a 30% decrease in exposure to broad-spectrum antibiotics would be a 26% decrease in C. difficile infection.

The 30% cut in broad-spectrum use would be equivalent to about a 5% reduction in the proportion of inpatients getting any antibiotic, the report said.

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